A healthy heart for all: boosting cardiac surgery access in low-income countries
Authors: Ahmed K. Awad, Adham Ahmed, Omar A.A. Mohamed, Mohammed A. Rais
Journal: International Journal of Surgery (2023)

Dear Editor, It has been about 8 months since Russia invaded Ukraine, and the war does not appear to be ending anytime soon. As of October 2022, the United Nations (UN) had reported 6221 deaths, 972 of which were children1. There has also been a massive displacement of civilians with seven million Ukrainian refugees across Europe1. The devastation caused by this brutal war cannot be overstated; from constant terror attacks resulting in massive civilian deaths, war crimes of violence and rape cases, food shortages, infrastructure damages, and many others1,2. However, one major sector in Ukraine has been at the heart of the entire situation, and that is healthcare. As of October 17, the WHO has authenticated 623 attacks on healthcare since the start of the war1. Health infrastructures have been brutally targeted, causing catastrophic impact to healthcare delivery2. Before the Russian invasion, Ukraine's healthcare system, particularly the surgical sector, was facing significant gaps and challenges3. Also, there was a significant burden of surgical cases in Ukraine before the war, which was made worse because of the COVID-19 pandemic that accumulated elective surgeries backlog across the globe. This brutal war has clearly exacerbated the situation, putting the country's healthcare system on a knife-edge. With all of the destruction and limited resources, it is clear that emergency and surgery departments in hospitals must deal with overburdened cases of traumatic injuries during these hard times4. Ukraine's surgical capacity currently lacks the necessary resources to deal with these outrageous burdens. With damaged hospital infrastructure, insufficient health professionals in the emergency and surgical departments, and inadequate surgical equipment, the country's surgical capacity clearly requires massive assistance. Ukrainian healthcare workers' brevity, commitment, and professionalism have been highly visible and acknowledged4. Furthermore, the incredible efforts and response of the world since the beginning of this war cannot be overstated. Massive humanitarian aid, as well as good deliveries of healthcare equipment and various financial aids for healthcare support, have been delivered. Most importantly, health officials from around the world have made sacrifices and risked their lives to be in Ukraine and along its borders to support Ukrainian healthcare workers, even during these threatening circumstances1. With Russia's current brutal attacks on major cities, the duration of this war is clearly unpredictable, necessitating a long-term support plan for Ukrainian healthcare, particularly surgical capacity. The surgical capacity is a highly complex and costly field that necessitates enormous efforts and resources to maintain. We urge international communities, governments, and organizations to assist Ukraine in strengthening its surgical sector by assisting in the establishment of new surgical clinics in nonaffected or least-affected western regions. The new facilities could be built underground to avoid damage from shelling and explosions. These facilities could also incorporate telesurgery into their services, allowing surgeons to operate remotely without putting their lives in danger. In war-torn areas, temporary hospitals should also be established underground to prevent disruption of care during shelling and explosions, with the goal of providing first aid care to patients who require immediate assistance. Furthermore, specialized trauma units should be established to provide trauma care to injured civilians. Continuous supplies of surgical equipment and assistance in transporting affected patients to war-free regions of the country and neighboring countries for ongoing care are still required. Securing a safe passage for delivery of life-saving supplies and humanitarian aids is crucial. The Ukrainian government should maintain its efforts to support healthcare workers and ensure equitable resource distribution across all sectors. Neighboring countries should continue to extend humanitarian aid to Ukraine by reducing the surgical caseload by performing surgeries on Ukrainian refugees during wartime. They can also begin planning to assist in reducing the post-war surgical backlog, particularly for emergency or oncological surgeries. Furthermore, surgical education and training should be maintained to ensure that post-war surgical capacity is adequate to meet demand. Telementoring or remote training should be considered between Ukrainian surgeons or trainees and other global experts. Above all, the international community should vehemently condemn acts of violence and intentional attacks on healthcare facilities and personnel around the world. Ethical approval Not applicable. Sources of funding None. Author's contribution A.A.W. and J.C.N. conceptualized the ideas. A.A.W., J.C.N., and L.D. reviewed and edited the manuscript. All authors were involved in data curation and writing of initial draft. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Andrew A. Wireko.